Provider Demographics
NPI:1275585515
Name:PAUL, IAN M (MD)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:M
Last Name:PAUL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 854
Mailing Address - Street 2:MC A410
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0854
Mailing Address - Country:US
Mailing Address - Phone:717-531-8521
Mailing Address - Fax:
Practice Address - Street 1:35 HOPE DR
Practice Address - Street 2:SUITE 102
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2086
Practice Address - Country:US
Practice Address - Phone:717-531-7300
Practice Address - Fax:717-531-3527
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD073552L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018468210001Medicaid
H38827Medicare UPIN
PA0018468210001Medicaid